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随着社会的不断发展,医疗制度改革程度不断加深,有关医疗档案管理的问题成为了重点之一。医疗档案是一种对病人诊治过程详细记载书面文件,内容不仅包括疾病的发生和变化情况,也包括了收治医院对于病患的诊断、治疗过程。完整有效的医疗档案不仅可以作为医学研究的重要临床参考资料,而且在发生医疗纠纷事件时,还可作为证明文件出现,具有法律效力。近年来,由于医护人员对于医疗档案的重视程度不断下降,医疗档案的管理问题愈发增多。我院统计2013
With the continuous development of society, the degree of medical system reform has been deepening. The issue of medical file management has become one of the focuses. Medical records is a detailed record of the patient’s diagnosis and treatment process documented documents, including not only the occurrence and change of the disease, but also includes the treatment of patients admitted to the hospital for the diagnosis and treatment process. A complete and effective medical record can not only serve as an important clinical reference for medical research, but also be used as a supporting document in the event of a medical dispute and have legal force. In recent years, due to the decreasing emphasis of medical staff on medical files, the management of medical files has become more and more serious. Our hospital statistics 2013